Right Care: How to reduce waste

This fourth and last post related to the series "Right Care" from the Lancet magazine ("Definition, gray areas and reversion" was the first, "Between too much and too little", the second, and "Question of attitude", the third), talks about various proposals to reduce the waste with the understanding that the inadequacy in the provision of health services is a wicked problem for which there are no magic solutions and, for this reason, the article "Levers for addressing medical underuse and overuse: achieving high-value health care" makes an effort, which is appreciated, to provide useful ideas to incorporate into the working agendas of both clinical managers and health managers, according to the following proposals to increase the value that health systems should bring to people.

Right Care: focusing on the attitude

Continuing with the "Right Care" series of the Lancet magazine, in this third post (I recall that "Definition, gray areas and reversion" was the first, and "Between too much and too little", the second), I have taken into account the beliefs of patients who, according to Vikas Saini in "Drivers of poor medical care," encourage practices of little value, but I have also described the attitudes of doctors who don’t prioritise the value of clinical practices. Remember that, according to Donald Berwick, between 25% and 33% of health costs are wasted in medical actions that don’t contribute anything or do more harm than good.

Right Care: between too much and too little

In the "Right Care" series of the Lancet magazine, Donald Berwick, in "Avoiding overuse - the next quality frontier", says that inappropriate clinical practices consume between 25% and 33% of health budgets in all countries in the world, but beyond the staggering amount of so much wasted money, there are four characteristics of excess, which Berwick emphasises: a) they affect the full range of health services and all specialties, although unevenly; b) there are specific clinical processes where exaggeration is highly disproportionate; (c) they are not exclusive to rich countries being also found in developing countries and in poor countries, in the latter group still with some dramatic traits, and d) are not related to the greater consumption of resources, since wastage can also be found in areas with less frequencies. 

Some figures of world-wide overuse

In direct observation studies in the first report of the "Right Care" series, it’s estimated that 57% of the antibiotics consumed in China should not have been prescribed, that between 16% and 70% of US hysterectomies are not justified, that 26% of knee arthroplasties in Spain could have been avoided and that 30% of coronary angiographies performed in Italy should not have been indicated. To end this compilation, it’s estimated that there are 6.2 million caesarean sections in excess in the world, half of them in Brazil and China.

Right Care: definition, gray areas and reversals

One of the Right Care Alliance initiatives, led by Vikas Saini and Shannon Brownlee from the Lown Institute in Boston, has been the compiling of 4 reports that are analyzing the misuse, by excess and by default, of health resources from a global perspective.

What does the Lown Institute mean by "right care"?

Before defining the concept of "right care", we must take note of Donald Berwick's definition of quality in the introductory article of the series. The author believes that the quality of care, as we understand it, is too focused on the guarantee of procedures and, despite being correct, the question now is: what do the inappropriate clinical processes mean for people’s health? Berwick states that quality should be understood as the provision of services that respond to people's real needs. So, practically, appropriatness has been filtered in the realm of quality.

When less is more: a strategic agenda

When Less Is More: Issues Of Overuse In Health Care – Health Affairs Blog http://t.co/9BabaZFFUY

— Joan Figueres Sendra (@joan_figueres) April 26, 2014

Dr. Joan Figueres, expert in the evaluation of health services, announces with his tweet, of the publication of a post signed by Shannon Brownlee and Vikas Saini, Vice President and respectively President of Lown Institute, along with Christine Cassel, President of ABIM Foundation. This post was published on the blog of Health Affairs on 25 April and in total agreement with Dr. Figueres, I also find it remarkable as I believe that the article does a good overview of the current grade of clinical waste outbreaks and suggests some strategies for engaging physicians, patients and the media in improving the situation, and I will focus on the latter:

"The Right Care Alliance" – The Statement of Principles

In 2012, The Lown Institute held a conference in Cambridge (Boston) with the motto "Avoiding Avoidable Care” which generated a statement aimed at creating a professional, academic and social movement in favour of a new health system that is sustainable, effective, rational, personalized and fair. You would think, of course, that the The Lown Institute refer only to the American system, which we all know is deeply unfair and expensive. And this would be so, if it wasn’t for the fact that, in a system like the Spanish, which is infinitely fairer than theirs, when we analyze it in detail we can also note the clinical practice’s undesirable variations of a scale comparable with the American’s.

For this reason, I think it's worth having a look at the statement promoted by The Lown Institute: "Declaration of Principles of the Right Care Alliance". Look at the following extract from the explanatory memorandum of the Declaration and judge whether they are timely or not:

• Modern medicine offers significant benefits, but at the same time also has a great ability to cause damage.
• The overuse of services is widespread and tacitly accepted by the modern healthcare system
• Overuse exposes patients to iatrogenic disease.
• Overuse distracts resources that could be used in real health needs or in investments in other non-health sectors that influence the health of people as social services, education, nutrition, etc.
• The health sector industry can distort clinical decisions to the point of betraying patients’ trust.